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Hypertension and quality of life among Afghan type-2 diabetic patients: A cross-sectional studyMehrab Neyazi
Department of Internal Medicine, Herat Regional Hospital, Herat, Afghanistan
Mohammad Naser Naseri
Bilal Ahmad Rahimi
Department of Pediatrics, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan.
Department of Public Health, Faculty of Medicine, Afghan International Islamic University, Kabul, Afghanistan.
Nosaibah Razaqi
Afghanistan Center for Epidemiological Studies, Herat, Afghanistan
Afghanistan Medical Students Association, Herat, Afghanistan
Faculty of Stomatology, Herat University, Herat, Afghanistan
Noorul Ain Katebi
Faculty of Medicine, Kandahar University, Kandahar, Afghanistan.
Parasto Amini
Afghanistan Center for Epidemiological Studies, Herat, Afghanistan
Kamran Iqbal
Faculty of Medicine, Kandahar University, Kandahar, Afghanistan.
Ahmad Neyazi
Afghanistan Center for Epidemiological Studies, Herat, Afghanistan
Faculty of Medicine, Kabul University of Medical Sciences, Kabul, Afghanistan
Corresponding author: Ahmad Neyazi
Email: neyazi.a@aces-af.org
Tel: +93790617023
Affiliation: Afghanistan Center for Epidemiological Studies, Herat-3001, Afghanistan
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Abstract
Background
The main objectives of this study were to study the prevalence and associated factors of hypertension and quality of life among DM outpatients in the Herat province of Afghanistan.
Methods
In this cross-sectional study, a total of 351 diabetic hospitalized patients were studied between January–June 2024. Health-related quality of life among diabetic patients was assessed using the World Health Organization Quality of Life (WHOQOL-BREF-26) questionnaire. Data were analyzed by using descriptive statistics, Chi-square tests, and multiple regression analysis. A two-tailed p-value below 0.05 was considered statistically significant.
Results
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The majority of patients were aged ≥50 years (59.3%), females (61.5%), illiterate (64.7%), and having low income (74.9%). Among these patients, 63.0% were overweight/obese and 51.0% experienced a significant negative event in the past month. The prevalence of hypertension among DM patients was 62.4%. Statistically significant factors associations with hypertension among DM patients were having > 5 children, having low economic status, being overweight/obese, and experiencing a negative event in the past month. Regarding the quality of life domains, 80.3%, 59.8%, 27.4%, and 53.8% of the study participants demonstrated low quality of life in the physical, psychological, social, and environmental domains, respectively.Conclusion
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The high prevalence of hypertension and poor quality of life among diabetic patients in Herat highlight the urgent need for integrated management strategies that address both blood pressure control and psychosocial well-being. Strengthening hospital-based screening, improving access to antihypertensive treatment, and implementing targeted interventions to improve quality of life could reduce the burden of diabetes-related complications in this population.Keywords:
Hypertension
Diabetes Mellitus, Type 2
Outpatients
Quality of Life
Afghanistan
Cross-Sectional Studies
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Introduction
Diabetes mellitus (DM) is a chronic metabolic disease. Globally, the prevalence of DM has increased from 200 million people in 1990 to 830 million in 2022, the majority living in low- and middle-income countries. In 2021, more than two million people globally died due to DM (World Health Organization, 2024).
Hypertension is a condition in which the blood pressure (BP) of a person is abnormally high, i.e., systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg (Chobanian et al., 2003)(Haile et al., 2023). Globally, approximately 1.28 billion adults aged 30–79 years are suffering from hypertension, with two-thirds of these patients living in low- and middle-income countries. Nearly half (46%) of the adults with hypertension are unaware that they have hypertension (World Health Organization, 2023).
Several studies from countries with healthcare systems and sociodemographic profiles comparable to Afghanistan report high burden of hypertension among people with type-2 diabetes and substantial impairments in health-related quality of life (HRQoL). Studies in Iran have documented important gaps in diabetes self-management and suboptimal control of cardiovascular risk factors among disadvantaged populations, including slum dwellers, which contributes to elevated risk of hypertension and poor HRQoL (Ghammari et al., 2024) (Ghammari et al., 2023).
Hypertension among DM patients is a global public health challenge and one of the main modifiable risk factors for other cardiovascular diseases and death (Lopez-Jaramillo et al., 2014). The prevalence of hypertension among type 2 DM patients is 32% to 82%, i.e., higher than that of age- and sex-matched patients without DM (Baskar et al., 2006). Meanwhile, compared to other cardiovascular disorders, hypertension is the most common comorbidity among DM patients (Kahya Eren et al., 2014).
In general, the quality of life (QoL) decreases in DM patients regardless of gender (Jorgetto et al., 2018). Patients with complications of DM suffer from different types of lifestyle problems. Finally, it affects the renal system by causing nephropathy, loss of vision, cardiac disorders, erectile dysfunction, and peripheral neuropathies which negatively affect the QoL (Prajapati et al., 2017).
Although there are few published articles from Afghanistan on hypertension (Saeed, 2017a)(Rahimi, Hemat, et al., 2020) and DM (Saeed, 2017b)(Rahimi, Mako, et al., 2020) separately, to our knowledge, only two researches have been published where hypertension is studied among DM patients, i.e., one is from Kabul (the capital city of Afghanistan) (Naseri et al., 2022) and the other from Southern Afghanistan (Kandahar and Lashkar Gah cities) (Stanikzai et al., 2025). Understanding the prevalence and determinants of hypertension and quality of life among outpatients with diabetes is essential for developing effective outpatient management programs and reducing long-term complications. However, there is no published study from the entire Western Afghanistan. Also, no published study from the entire Afghanistan has studied hypertension and quality of life among diabetic outpatients. Therefore, the main objectives of this study were to study the prevalence and associated factors of hypertension and quality of life among diabetic outpatients in the Herat province of Afghanistan.
Materials and Methods
Study Design, Participants, and Procedure
A cross-sectional study was conducted between January 1 and June 30, 2024, in Herat province, Afghanistan. The study population comprised adult patients with a confirmed diagnosis of type-2 diabetes mellitus who were visited hospitals during the study period. A convenience cluster sampling approach was used, where clusters were defined as hospitals. Three major public hospitals in Herat province were purposefully selected because they provide the majority of diabetes-related outpatient care in the region. Within these hospitals, all eligible diabetic outpatients present during the data collection shifts were invited to participate, ensuring consecutive recruitment to minimize selection bias. Eligibility criteria included: (1) confirmed diagnosis of type-2 diabetes mellitus (verified via medical records), (2) hospitalization within the selected hospitals, and (3) provision of written informed consent. Patients who were critically ill, pregnant, or unable to communicate were excluded. Of the 400 eligible patients approached, 351 consented and completed the questionnaire, yielding a response rate of 87.8%. Data collection was conducted through structured, interviewer-administered questionnaires, and trained data collectors followed standardized procedures to ensure reliability and completeness.
Measures
The study questionnaire comprised three sections: sociodemographic information, blood pressure measurement, and quality of life assessment. Sociodemographic data included information on age group, gender, marital status, residency, total number of children, education level, economic status, and body mass index (BMI) category. Participants were also asked about the occurrence of any adverse event in the past month, defined as any incident that had a negative impact on their mental well-being (e.g., family conflict, financial crisis, loss of a loved one). Responses were recorded as “yes” or “no.”
Health-related quality of life among diabetic patients was assessed using the World Health Organization Quality of Life (WHOQOL-BREF-26) questionnaire. This validated instrument evaluates four key domains of quality of life: physical health, psychological well-being, social relationships, and environmental factors. Each item is rated on a 5-point Likert scale, with higher scores indicating better quality of life.
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The total scores for each domain were categorized into low, moderate, and high quality of life based on standard WHOQOL-BREF guidelines. The internal consistency of the instrument, as reflected by Cronbach’s alpha, was 0.86 in the present study.Blood pressure measurements were obtained twice for each participant using a calibrated sphygmomanometer in the standard sitting position after at least 5 minutes of rest. The first measurement was taken before the interview and the second measurement after the interview, and the mean of these two readings was used as the final blood pressure value. Participants were classified as hypertensive if they had a systolic blood pressure of ≥ 140 mmHg, a diastolic blood pressure of ≥ 90 mmHg, or both. All participants were not on antihypertensive treatment, and none had pharmacologically controlled blood pressure during the study period.
Statistical Analysis
Data were entered into Microsoft Excel 2016 and analyzed using IBM SPSS version 26.0 for Windows. Descriptive statistics (mean, standard deviation, frequency, and percentage) were used to summarize participant characteristics. Associations between categorical variables (e.g., hypertension status and sociodemographic factors) were assessed using Pearson’s Chi-square test. To identify independent predictors of hypertension, a multiple logistic regression model was constructed. Variables with a p-value < 0.05 in bivariate analysis and clinically important factors (age, sex, BMI, income status) were included in the initial model. Backward stepwise selection was applied to derive the final model, and adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported. A p-value < 0.05 was considered statistically significant. All participants were interviewed in person, and questionnaires were completed in full. There were no missing data for any of the study variables.
Results
A total of 351 diabetic patients participated in the study, with the majority aged 50–95 years (59.3%) and females (61.5%). Most were married (83.5%) and resided in urban areas (62.1%). Nearly half had more than five children (49.6%), and a significant proportion were illiterate (64.7%), with only 6.0% having attained university education. Economic status was predominantly low, with 74.9% classified as low-income. In terms of BMI, 43.9% were overweight, 19.1% were obese, 33.6% had normal weight, and 3.4% were underweight. Additionally, 51.0% of participants reported experiencing a significant negative event in the past month. [Table 1]
Characteristic | Categories | Frequency (n) | Percentage (%) |
|---|---|---|---|
Age group | 18–49 years 50–95 years | 143 208 | 40.7 59.3 |
Gender | Male Female | 135 216 | 38.5 61.5 |
Marital status | Single Married Widow/divorced | 3 293 55 | 0.9 83.5 15.7 |
Residency | Urban Rural | 218 133 | 62.1 37.9 |
Total number of children | None 1–5 > 5 | 11 166 174 | 3.1 47.3 49.6 |
Education | Illiterate Primary school Secondary school High school University | 227 63 18 22 21 | 64.7 17.9 5.1 6.3 6.0 |
Economic status | High-income Middle-income Low-income | 11 77 263 | 3.2 21.9 74.9 |
BMI | Underweight Normal weight Overweight Obesity | 12 118 154 67 | 3.4 33.6 43.9 19.1 |
Bad event occurring in the past month | Yes No | 179 172 | 51.0 49.0 |
Regarding the quality of life domains, the physical domain showed the highest proportion of participants in the low category (80.3%), with only 14.0% and 5.7% in the moderate and high categories, respectively. In the psychological domain, 59.8% of participants reported a low quality of life, while 29.6% and 10.5% had moderate and high scores, respectively. The social domain demonstrates a more even distribution, with 27.4% in the low category, 31.6% in the moderate, and 41.0% in the high category. The environment domain follows a similar pattern, with 53.8% of participants reporting a low quality of life, 41.3% moderate, and only 4.8% high. [Figure 1]
Fig. 1
Domains of the quality of life in the study participants (n = 351).
Hypertension was prevalent in 62.4% of participants, with no significant association observed with age (p-value = 0.618), gender (p-value = 0.236), marital status (p-value = 0.520), residency (p-value = 0.254), or education level (p-value = 0.548). However, significant associations were found between hypertension and the number of children (p-value = 0.031), economic status (p-value = 0.029), BMI (p-value = 0.018), and experiencing a negative event in the past month (p-value = 0.013). Participants with more than five children (66.1%) and those from low-income backgrounds (65.0%) had a higher prevalence of hypertension. Additionally, overweight (66.9%) and obese (71.6%) individuals exhibited higher hypertension rates compared to those with normal weight (53.4%) or underweight (41.7%). Furthermore, those who experienced a significant negative event in the past month had a higher prevalence of hypertension (68.7%) compared to those who did not (55.8%). [Table 2]
Characteristic | Categories | Blood Pressure | p-value | |
|---|---|---|---|---|
Normotensive | Hypertensive | |||
N (%) | N (%) | |||
Age group | 18–49-years 50–95-years | 56 (39.2) 76 (36.5) | 87 (60.8) 132 (63.5) | 0.618 |
Gender | Male Female | 56 (41.5) 76 (35.2) | 79 (58.5) 140 (64.8) | 0.236 |
Marital status | Single Married Widow/divorced | 2 (66.7) 111 (37.9) 19 (34.5) | 1 (33.3) 182 (62.1) 36 (65.5) | 0.520 |
Residency | Urban Rural | 87 (39.9) 45 (33.8) | 131 (60.1) 88 (66.2) | 0.254 |
Total number of children | None 1–5 > 5 | 8 (82.7) 65 (39.2) 59 (33.9) | 3 (27.3) 101 (60.8) 115 (66.1) | 0.031 |
Education | Illiterate Primary school Secondary school High school University | 90 (39.6) 22 (34.9) 6 (33.3) 5 (22.7) 9 (42.9) | 137 (60.4) 41 (65.1) 12 (66.7) 17 (77.3) 12 (57.1) | 0.548 |
Economic status | High-income Middle-income Low-income | 8 (72.7) 32 (41.6) 92 (35.0) | 3 (27.3) 45 (58.4) 171 (65.0) | 0.029 |
BMI | Underweight Normal weight Overweight Obesity | 7 (58.3) 55 (46.6) 51 (33.1) 19 (28.4) | 5 (41.7) 63 (53.4) 103 (66.9) 48 (71.6) | 0.018 |
Bad event occurring in the past month | Yes No | 56 (31.3) 76 (44.2) | 123 (68.7) 96 (55.8) | 0.013 |
Total | 132 (37.6) | 219 (62.4) | ||
No significant associations were observed between hypertension and overall self-rated quality of life (p-value = 0.430), health satisfaction (p-value = 0.654), or physical (p-value = 0.068), psychological (p-value = 0.710), and environmental (p-value = 0.630) quality of life domains. However, a significant association was found in the social relationship domain (p-value = 0.040), where individuals with low social relationship scores had a lower prevalence of hypertension (52.1%) compared to those with moderate (64.0%) and high (68.1%) scores. [Table 3]
Quality of life | Categories | Blood Pressure | p-value | |
|---|---|---|---|---|
Normotensive | Hypertensive | |||
N (%) | N (%) | |||
How would you rate your quality of life? | Very poor Poor Neither poor nor good Good Very good | 14 (35.0) 35 (33.7) 44 (36.4) 38 (46.3) 1 (25.0) | 26 (65.0) 69 (66.3) 77 (63.6) 44 (53.7) 3 (75.0) | 0.430 |
How satisfied are you with your health? | Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied | 9 (26.5) 49 (38.6) 48 (38.4) 25 (41.0) 1 (25.0) | 25 (73.5) 78 (61.4) 77 (61.6) 36 (59.0) 3 (75.0) | 0.654 |
Physical domain | Low Moderate High | 98 (34.8) 23 (46.9) 11 (55.0) | 184 (65.2) 26 (53.1) 9 (45.0) | 0.068 |
Psychological domain | Low Moderate High | 79 (37.6) 37 (35.6) 16 (43.2) | 131 (62.4) 67 (64.4) 21 (56.8) | 0.710 |
Social relationship domain | Low Moderate High | 46 (47.9) 40 (36.0) 46 (31.9) | 50 (52.1) 71 (64.0) 98 (68.1) | 0.040 |
Environment domain | Low Moderate High | 68 (36.0) 56 (38.6) 8 (47.1) | 121 (64.0) 89 (61.4) 9 (52.9) | 0.630 |
Total | 132 (37.6) | 219 (62.4) | ||
Discussion
In this study, 80.3%, 59.8%, 27.4%, and 53.8% of the patients demonstrated low quality of life in the physical, psychological, social, and environmental domains, respectively. Increased chances of hypertension were present in DM patients with moderate and high social relationship scores.
In a study conducted among 609 DM patients in Kandahar and Lashkar Gah cities of Southern Afghanistan, the prevalence of hypertension among DM patients was 55.3%. The main factors associated with hypertension among DM patients were female gender (adjusted odds ratio [AOR] 1.73, 95% CI 1.09–2.74), aged ≥ 50 years (AOR 4.35, 95%CI 2.78–2.6.81), having diabetes for ≥5 years (AOR 2.13, 95%CI 1.37–3.31), poor glycemic control (AOR 1.80, 95%CI 1.18–2.75), and presence of depressive symptoms (AOR 3.25, 95%CI 2.59–4.80) (Stanikzai et al., 2025).
In a cross-sectional study conducted among 321 DM patients in Kabul city of Afghanistan, the prevalence of hypertension among DM patients was 70.5%. hypertension was more prevalent in women (76.8%), with mean systolic and diastolic blood pressures of 146.9 mmHg and 89.6 mmHg, respectively. Moreover, the mean duration of DM, HbA1c values, and body mass index (BMI) of the study participants were 7.1 years, 9.3%, and 28.8, respectively (Naseri et al., 2022).
A hospital-based cross-sectional study conducted in Al-Kharj, Saudi Arabia, among 1178 diabetic patients revealed that the prevalence of uncontrolled hypertension among DM patients was 71.8%. The main factors associated with uncontrolled hypertension were age > 65 years (OR 2.0, 95%CI 1.1–3.8), male gender (OR 1.5, 95%CI 1.0–2.2), and obesity (OR 2.4, 95%CI 1.6–3.5) (Almalki et al., 2020).
In Southwest Ethiopia, a hospital-based cross-sectional study was conducted among 366 DM patients. The prevalence of hypertension among DM patients was 37.4%. The main factors associated with hypertension among DM patients were age ≥ 50 years (AOR 4.8, 95% CI 1.4–16.4], overweight/obese (AOR 3.1, 95% CI 1.6–6.1), and khat chewing (AOR 19.3, 95% CI
10.3–36.4) (Abdissa et al, 2020).
In the current study, overweight/obesity was a statistically significant risk factor for hypertension among DM patients. This finding is in agreement with the existing literature showing the higher probability of hypertension among obese adults (Dua et al., 2014)(Drøyvold et al., 2005)(Chorin et al., 2015)(Abebe et al., 2015). In the literature, the association between obesity and hypertension is poorly understood, i.e., mechanisms through which obesity directly causes hypertension and increases disease progression are complex and have still been intensively studied (Hall et al., 2000)(Haynes et al., 1997)(Kotsis et al., 2010).
However, fortunately, obesity among adult DM patients can be controlled by designing an effective prevention plan, such as increasing public health awareness and encouraging DM patients to bring lifestyle changes, including specific diet and exercise recommendations, which could help in decreasing weight and raise their levels of blood pressure control.
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In Bantul, Indonesia, a cross-sectional study was conducted to evaluate the level of adherence and quality of life of 143 DM patients with hypertension. For measuring the level of treatment adherence, the Modified Morisky Medication Adherence Scale was used, while the SF36 questionnaire was used to measure the quality of life. The majority (76.3%) of respondents had moderate (39.2%) and low (37.1%) levels of adherence. The mean score of quality of life was 61.96 ± 12.48. Relatively low medication adherence and quality of life were observed among DM patients with hypertension. DM patients who were male and college-educated had higher medication adherence (OR > 1, p-value < 0.05) (Akrom & Anggitasari, 2019).This study had a few limitations. First, data for this study was collected from Herat province only, one of the 34 provinces of Afghanistan. So, we cannot generalize our results to the diabetic patients of the entire Afghanistan. Second, we collected data through face-to-face interviews. Therefore, there are more chances of recall bias. Third, we did not include many important associated factors, such as the presence of comorbidities of diabetes mellitus, duration of the T2DM, complications of T2DM, and HbA1c levels of the study participants. Fourth, it was a cross-sectional study. So, the nature of the data did not allow for causal inferences regarding associated factors that might affect the prevalence of hypertension among DM patients. Fifth, due to very limited funding for this study, we could not assess dyslipidemia, a potential risk factor for hypertension among DM patients, in our study participants.
Conclusion and recommendation
The results of this study are important and give useful information in order to guide policymakers for policies and interventions on hypertension among patients with diabetes who have been lacking adequate care. There is a high prevalence of hypertension and low quality of life among DM patients in Herat province of Afghanistan. Factors associated with depression were being female, having low economic status, and having had a bad event in the past month. The main factors associated with hypertension among DM patients were having > 5 children, having low economic status, being overweight/obese, and experiencing a negative event in the past month. Meanwhile, increased chances of hypertension were present in DM patients with moderate and high social relationship scores. The findings of this study suggest that while most quality-of-life aspects were not significantly associated with hypertension, social relationships may play a role in its prevalence among diabetic patients.
It is highly recommended that all diabetic patients who seek medical contact should be screened for hypertension and its complications as well as quality of life. Afghanistan Ministry of Public Health, as well as international donor agencies such as WHO and UNICEF, should work in collaboration to design appropriate preventive strategies targeting the modifiable risk factors associated with hypertension. There is an intense need for more studies, especially prospective cohort studies with larger sample sizes, to be conducted in all 34 provinces of Afghanistan (both rural and urban areas) to find out the real burden and risk factors of hypertension among DM patients in the Afghan population. Future studies should also investigate other factors that predispose DM patients to hypertension, such as dyslipidemia, medication adherence, dietary patterns, concomitant medical conditions, and corticosteroid use.
Acknowledgment
We are cordially thankful to the officials and personnel of all the hospitals of Herat Province who helped us in this research. We are also grateful to all the study participants for their cooperation and participation in our study.
Declarations
Ethical approval and consent to participate
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The current research received ethical approval from the Ethical Committee of the Afghanistan Center for Epidemiological Studies, with the assigned reference number #23.1.017. Before engaging participants, the study's aims and procedures were thoroughly elucidated. A
Written informed consent was secured from all participants prior to their inclusion, and they were explicitly informed of their right to withdraw from the study at any point without consequence. A
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All methodologies and processes were conducted in strict compliance with applicable ethical principles and regulatory frameworks.Conflict of interest
The authors assert that there are no conflicts of interest to disclose.
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Author Contribution
•MNN designed the study.•MNN contributed to the data collection of this study.•AN analyzed the data.•BAR, NR, MN, NAK, PA, KI and AN prepared the draft of the manuscript.•AN critically reviewed, rewrote, edited, and finalized the manuscript.•All authors reviewed the manuscript.
MNN contributed to the data collection of this study.
AN analyzed the data.
BAR, NR, MN, NAK, PA, KI and AN prepared the draft of the manuscript.
AN critically reviewed, rewrote, edited, and finalized the manuscript.
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All authors reviewed the manuscript.A
Funding
This research received no external funding.
Consent for publication
Not applicable.
Clinical trial number
Not applicable.
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Data Availability
The datasets utilized and/or analyzed in the course of the present study are accessible from the corresponding author upon reasonable inquiry.
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